ORIGINAL

Morgado FL et al. Correlation ARTICLE

between GCS and CT findings in traumatic brain injury

Correlation between the Glasgow Coma Scale

and computed tomography imaging findings in patients
with traumatic brain injury*
Correlao entre a escala de coma de Glasgow e os achados de imagem de tomografia computadorizada
em pacientes vtimas de traumatismo cranioenceflico

Fabiana Lenharo Morgado1, Luiz Antnio Rossi2

Abstract Objective: To describe the correlation between the Glasgow Coma Scale, risk factors, age, sex and tracheal intubation
with the cranial computed tomographic findings in patients with traumatic brain injury. Materials and Methods: A
prospective, cross sectional study was developed with 102 patients who were given a Glasgow coma score and submitted
to computed tomography at the first 12 hours following admission. Results: The mean age of the entire series was
37.77 18.69 years, with prevalence of male patients (80.4%). The most common causes of head injury were:
automobile accidents (52.9%), falls (20.6%), pedestrian injuries (10.8%), falls to the ground (7.8%) and aggression
(6.9%). In the present study, 82.4% of patients had traumatic brain injury rated as mild, 2.0% as moderate and 15.6%
as severe. Tomographic findings such as subgaleal hematoma, skull fractures, subarachnoid hemorrhage, cerebral
contusion, extra-axial blood collection and diffuse cerebral edema were observed in 79.42% of the patients. Most of
the findings of severe traumatic brain injury were observed in the patients above 50 years (93.7%) and in this group,
all the patients required tracheal intubation. Conclusion: Statistical significance was observed in the correlation between
the Glasgow Coma Scale, age > 50 years (p < 0.0001), need for tracheal intubation (p < 0.0001) and CT findings.
Keywords: Head injury; Glasgow Coma Scale; Epidemiology; Computed tomography.

Resumo Objetivo: Determinar a correlao da escala de coma de Glasgow, fatores causais e de risco, idade, sexo e intubao
orotraqueal com os achados tomogrficos em pacientes com traumatismo cranioenceflico. Materiais e Mtodos:
Foi realizado estudo transversal prospectivo de 102 pacientes, atendidos nas primeiras 12 horas, os quais receberam
pontuao segundo a escala de coma de Glasgow e foram submetidos a exame tomogrfico. Resultados: A idade
mdia dos pacientes foi de 37,77 18,69 anos, com predomnio do sexo masculino (80,4%). As causas foram: acidente
automobilstico (52,9%), queda de outro nvel (20,6%), atropelamento (10,8%), queda ao solo ou do mesmo nvel
(7,8%) e agresso (6,9%). No presente estudo, 82,4% dos pacientes apresentaram traumatismo cranioenceflico de
classificao leve, 2,0% moderado e 15,6% grave. Foram observadas alteraes tomogrficas (hematoma subgaleal,
fraturas sseas da calota craniana, hemorragia subaracnoidea, contuso cerebral, coleo sangunea extra-axial, edema
cerebral difuso) em 79,42% dos pacientes. Os achados tomogrficos de trauma craniano grave ocorreram em maior
nmero em pacientes acima de 50 anos (93,7%), e neste grupo todos necessitaram de intubao orotraqueal. Con-
cluso: Houve significncia estatstica entre a escala de coma de Glasgow, idade acima de 50 anos (p < 0,0001),
necessidade de intubao orotraqueal (p < 0,0001) e os achados tomogrficos.
Unitermos: Trauma craniano; Escala de coma de Glasgow; Epidemiologia; Tomografia computadorizada.
Morgado FL, Rossi LA. Correlation between the Glasgow Coma Scale and computed tomography imaging findings in patients with
traumatic brain injury. Radiol Bras. 2011 Jan/Fev;44(1):3541.

INTRODUCTION
Traumatic brain injury (TBI) is defined
as an aggression to the brain caused by an
external physical force that may produce a
* Study developed at Conjunto Hospitalar de Sorocaba, Soro-
caba, SP, Brazil.
1. MD, Trainee of Radiology and Imaging Diagnosis at Con-
junto Hospitalar de Sorocaba, Sorocaba, SP, Brazil.
2. PhD, Professor at Pontifcia Universidade Catlica de So
Paulo (PUC-SP), Coordinator for the Program o Training in Radi-
ology and Imaging Diagnosis, Conjunto Hospitalar de Sorocaba,
Sorocaba, SP, Brazil.
state of diminished or altered consciousness
and, consequently, affecting cognitive abili-
ties or physical function. It may be tempo-
rary or permanent, and may cause partial or
total impairment of such functions(1).
Traumatic brain injury constitutes one
of the main health problems worldwide,
Mailing Address: Dra. Fabiana Lenharo Morgado. Avenida Onze
de Junho, 600, ap. 172, Vila Clementino. So Paulo, SP, Brazil,
04041-002. E-mail: fabimorgado@hotmail.com
Received April 11, 2010. Accepted after revision November
19, 2010.
currently with a high and increasing inci-
dence, representing an important cause of
morbimortality among adolescents and
young adults. It directly contributes to
deaths by external causes, the main ones
being car accidents, falls, aggressions and
pedestrian run over. In Brazil in the year of
2008, the largest mortality rates due to such
causes occurred in the Southeast and
Northeast regions(1).
The initial assessment of a patient with
TBI includes the Glasgow Coma Scale

Radiol Bras. 2011 Jan/Fev;44(1):3541 35

0100-3984 Colgio Brasileiro de Radiologia e Diagnstico por Imagem
Morgado FL et al. Correlation between GCS and CT findings in traumatic brain injury
(GCS), data regarding the accident and
computed tomography (CT). It is essential
to determine the cause of the trauma, the
impact intensity, presence of neurological
symptoms, convulsion, and particularly
document any reports on loss of conscious-
ness(2), time elapsed between the accident
and the examination, vomits and seizures(3).
According to the GCS, traumatic brain
injuries are classified as mild, moderate or
severe. The GCS was initially described by
Teasdale & Jennet(4) in 1974, and is cur-
rently the most widely used parameter for
assessment of consciousness level, as
amongst its advantages, it comprises a set
of very simple and easy-to-perform physi-
cal examinations(4).
Until 19 years ago, radiography was the
main imaging method recommended in
emergency evaluations, where a sign of
fracture was considered a risk factor. The
protocols were then modified to include
CT, GCS and the presence of cranial frac-
ture a risk factor.
Currently the imaging method of choice
for the diagnosis and prognosis of TBI is
CT(5), which is also instrumental in the
management of the lesions progression.
Results reported in studies investigating the
indications cranial CT in cases of TBI are
controversial. Several studies attempt to
establish clinical indicators to justify the
non use of cranial CT in certain cases of
TBI as a contribution to costs reduction in
the health system(69).
The most recent protocols indicate CT
within the first three hours following
trauma in patients with GCS < 15 and GCS
= 15 presenting with one or more of the
following findings: convulsion, headache,
vomiting, amnesia and/or syncope(10), age
group extremes, focal neurological deficit,
suspicion of intoxication, visible cranial
trauma and history of coagulopathies(1).
Computed tomography findings in TBI
vary according to the trauma severity, that
is, in accordance with the GCS score. Dif-
ficulties were experienced in the compari-
son of tomographic findings, as there are
only few scientific studies with that pur-
pose in the literature. In the present study,
effort was made to investigate such find-
ings.
The relationship among types of brain
lesions demonstrated at CT, type of TBI
36
(severity of the lesion) and prognosis are
described by several authors in the litera-
ture(11,12), all of them reporting approxi-
mately the same variation: the more severe
the TBI is, more numerous and severe are
the findings at CT.
In the present study, besides the evalu-
ation of causal factors, age, gender and risk
factors with GCS score and CT findings,
the authors have also evaluated the inci-
dence of the need for orotracheal intubation
in TBI patients, which may become another
important parameter in the assessment of
a patient in the emergency room.
The proposal of a prospective study
with a single observer classifying the pa-
tients according to the GCS, and a single
radiologist evaluating the CT images,
makes the present study peculiar, as the
possible interobserver variability in the
scoring and images description is taken into
consideration.
MATERIALS AND METHODS
One hundred and two patients above 12
years of age were prospectively studied.
Among these patients, 82 (80.4%) were
men with mean age corresponding to 37.77
(standard deviation 18.69 years) and
79.4% (81/102) were below 50 years of
age. The patients were randomly selected
in the period from January to May/2009, as
they were admitted to the emergency unit
of a reference trauma center at a hospital
in the city of Sorocaba, SP, Brazil, within
the first 12 hours following TBI.
The patients were evaluated with re-
spect to GCS and admission CT findings
and correlated with clinical data such as:
sex, age group, race, risk factors related to
the trauma (headache, vomiting, amnesia,
syncope and/or convulsion) and unrelated
risk factors (coagulopathy, age > 50 years,
drugs or alcohol use, epilepsy, previous
neurological surgery and/or smoking), and
presence or not of endotracheal intubation.
Exclusion criteria were the following:
age < 12 years, tomographic or clinical di-
agnosis of stroke, other lesions of non-trau-
matic nature, and patients with a TBI diag-
nosis for longer than 12 hours.
After emergency care, the patients were
taken to the CT unit, where a neurological
evaluation was performed, always by the
same radiologist. Demographics and risk
factors were also collected at that moment,
based on answers from the patients them-
selves, or whenever that was not possible,
by witnesses and/or patients companions
reports.
Traumatic brain injuries with GCS
scores between 13 and 15 were classified
as mild, while those between 9 and 12 were
classified as moderate, and those between
3 and 8 were classified as severe(4). All the
patients included in the study were submit-
ted to cranial CT without intravenous ad-
ministration of a contrast agent.
All the cranial CT scans were performed
with the patient in dorsal decubitus, with a
single slice, helical Somaton Balance CT
equipment (Siemens Medical Solutions;
Erlangen, Germany), utilizing 130 kVp and
80 mAs. Axial, sections were performed,
parallel to the infraorbitomeatal line, with
5 mm-thick slices in the region of the pos-
terior fossa and 10 mm at the other areas
of the skull.
All the cranial CT images were ana-
lyzed, both on soft tissue windows (200 W
and 40 C for the skull base and 80 W and
35 C for the brain) and the bone structures
(1500 W and 450 C), by a single physician
specialized in radiodiagnosis, with profes-
sional experience in a reference trauma
hospital.
Tomographic patterns
The following findings were utilized as
tomographic patterns: subgaleal hematoma,
calvarial fracture, basilar skull fracture,
area of cerebral contusion with hemor-
rhagic suffusion (Figure 1) and extraparen-
chymal blood collection, diffuse cerebral
edema, subarachnoid hemorrhage, pattern
of three or more findings (Figure 2).
RESULTS
In the present study sample, 82 patients
(80.4%) were men and 20 patients (19.6%)
were women. The mean age was 37.77
years, with a standard deviation of 18.69
years, with 79.4% of the patients under 50
years of age, 79.4% of the patients being
white and 20.6% blacks.
Most of the patients (86.3%) presented
with one or more risk factors related to the
trauma (headaches, vomiting, convulsion,
Radiol Bras. 2011 Jan/Fev;44(1):3541
Morgado FL et al. Correlation between GCS and CT findings in traumatic brain injury

Figure 1. Tomographic patterns. A: Subgaleal hematoma characterized by increase in volume and in the attenuation coefficients of left parietal extracranial
soft tissues on both images (arrows). B: Calvarial fracture characterized by solution of continuity in the left temporal bone (arrow 1) and fracture of bones of
the nasal pyramid and of the zygomatic arch at left (arrow 2 and 3, respectively) C: Basilar skull fracture characterized by bilateral solution of continuity in the
petrous temporal bone on both images (arrows 1 thru 4) and in the sphenoid-clival bone (arrow 5). D: Area of cerebral contusion with hemorrhagic suffusion
characterized by hyperdense areas intermingled with hypodense intraparenchymal areas in the bilateral temporal lobes (arrows 1 and 2) and in the bilateral
frontal lobes (arrows 3 and 4).

amnesia and/or syncope), and only 24.5%
presented with one or more unrelated risk
factors (coagulopathy, use of drugs or al-
cohol, previous neurological surgery, epi-
lepsy, age > 50 years, smoking).
The main causes for TBI were: car acci-
dents (52.9%) and fall from height (20.6%).
The distribution of patients in accor-
dance with consciousness level at the mo-
ment of the first aid was the following:
82.4% with mild TBI (GCS score 13),
15.6% with severe TBI (GCS score between
3 and 8) and 2.0% with moderate TBI
(GCS score between 9 and 12) (Figure 3).
Among the studied patients, 79.42%
(81/102) had alterations reported at CT,
with 71.6% of them presenting subgaleal
hematoma, 34.3% with craniofacial frac-
tures, 18.6% with subarachnoid hemor-
rhage, 10.8% with area of brain contusion
with hemorrhagic suffusion, 7.8% with
specific basilar skull fractures, 5.9% with
diffuse cerebral edema, and 5.9% with
extraparenchymal blood collection. Three
of more findings were observed in 18.6%
of the patients. All the patients with no
finding at CT (20.58%) presented mild TBI
at the moment of the diagnosis.
Orotracheal intubation was required in
18 (17.6%) patients, 15 of them with severe
TBI at the moment of the first aid.
By associating the different types of TBI
with the tomographic findings, one ob-
served that, of the 84 patients (82.4%) with
mild TBI, 56 presented subgaleal he-
matoma, 24 craniofacial fractures, eight
subarachnoid hemorrhage, five areas of
cerebral contusion with hemorrhagic suf-
fusion, two presented basilar skull frac-
tures, two presented diffuse cerebral
edema, two extraparenchymal blood col-
lection and seven presented three or more
associated findings (Figure 4). Another
important finding in the cases classified as
mild TBI was that only two patients were
older than 50 years, and both required
orotracheal intubation.
Two patients (2%) presented moderate
TBI, and one of them was older than 50
years and required orotracheal intubation
at the moment of the first aid. Such patient
presented subgaleal hematoma, diffuse ce-
rebral edema, craniofacial fractures, area of
cerebral contusion with hemorrhagic suf-
fusion, subarachnoid hemorrhage and as-
sociation of three or more findings at CT.
The other patient was below 50 years of age
and presented only subgaleal hematoma at
CT. None of these patients presented basi-
lar skull fracture or extraparenchymal
blood collection (Figure 5).
Severe TBI was observed in 16 patients
(15.6%), 15 of them (93.7%) aged above
50 years and requiring orotracheal intuba-
tion. Other tomographic findings were: 15
subgaleal hematomas, 10 subarachnoid

Radiol Bras. 2011 Jan/Fev;44(1):3541 37

Morgado FL et al. Correlation between GCS and CT findings in traumatic brain injury

Figure 2. Tomographic patterns. A: Extraparenchymal blood collection characterized by hyperdense concave frontotemporal image (arrow 1) and biconvex right
extracerebral temporal image (arrow 2). B: Diffuse cerebral edema characterized by attenuation of cortical sulci, ventricular system collapse, and diffuse loss
of definition of the white and gray substances. C: Subarachnoid hemorrhage characterized by the presence of hematic (hyperdense) content in the temporal
cortical sulci at right (arrow 1) and in the sylvian cistern and cerebellar tent at left (arrows 2 and 3) D: Pattern of association of three or more tomographic
findings characterized by fracture of the right frontal bone (arrow 1), subgaleal hematoma (arrow 2), subarachnoid hemorrhage (arrow 3) and area of cerebral
contusion with hemorrhagic suffusion (arrow 4).

Figure 3. Percentage of patients with different types of TBI (mild, moderate,
severe).
Figure 4. CT findings in patients with mild TBI. FT/BC, basilar skull fracture;
FT, craniofacial fractures; ECD, diffuse cerebral edema; HSG, subgaleal he-
matoma; HSA, subarachnoid hemorrhage; ACSH, area of cerebral contusion
with hemorrhagic suffusion; CSEP, extracranial hematoma; 3 ou +, three or
more findings at CT.

hemorrhage, 10 craniofacial fractures, 6
basilar skull fractures, 5 areas of cerebral
contusion with hemorrhagic suffusion, 4
extracranial hematoma, 3 diffuse cerebral
edemas and 11 with a pattern of three or
more findings (Figure 6).
It was observed that as the ages in-
creased, the TBI severity also increased
(Figure 7).
Statistical significance was observed
between the GCS scoring and the follow-
ing variables: CT findings (Table 1); need
for orotracheal intubation and coded age
(Table 2). The other variables sex, trauma
mechanism, race, trauma-related and unre-
lated risk factors did not present any sta-
tistical significance.

38 Radiol Bras. 2011 Jan/Fev;44(1):3541

Morgado FL et al. Correlation between GCS and CT findings in traumatic brain injury

Figure 5. CT findings in patients with moderate TBI. FT/BC, basilar skull
fracture; FT, craniofacial fractures; ECD, diffuse cerebral edema; HSG, subgaleal
hematoma; HSA, subarachnoid hemorrhage; ACSH, area of cerebral contu-
sion with hemorrhagic suffusion; CSEP, extracranial hematoma; 3 ou +, three
or more findings at CT.
Figure 6. CT findings in patients with severe TBI. FT/BC, basilar skull fracture;
FT, craniofacial fractures; ECD, diffuse cerebral edema; HSG, subgaleal he-
matoma; HSA, subarachnoid hemorrhage; ACSH, area of cerebral contusion
with hemorrhagic suffusion; CSEP, extracranial hematoma; 3 ou +, three or
more findings at CT.

has been increasing(14,15), with the highest

Figure 7. Distribution of patients with ages above 50 years with different types of TBI.
DISCUSSION
Traumatic brain injury is an important
public health problem. International mor-
tality statistics show that accidents are ac-
countable for 3% to 10% of all deaths for
all causes, and the problem takes on greater
magnitude considering that most of these
deaths occur in young patients(13). In Bra-
zil, the number of deaths by external causes
rates in the Southeastern and Northeastern
regions(16).
In the present study, 80.4% (82/102) of
the patients with TBI were men. Similar
statistics were observed in several epide-
miological studies available in the litera-
ture(1723). Such a fact is attributed to a
greater exposure of male individuals to risk
factors for TBI such as accidents with mo-
tor vehicles and violence. In general, the
number of men with access to automobiles
is higher than the number of women, and
more men work away from home than
women, thus being more exposed to risk
conditions. Also, the higher incidence of
TBI in male individuals is related to loca-
tions with higher urban violence rates(24).

Table 1 Statistical correlation between GCE and CT findings.

Three or more
FT/BC FT ECD HSG HSA ACSH CSEP CT findings

Mild TBI 2 24 2 56 8 5 2 7
Moderate TBI 0 1 1 2 1 1 0 1
Severe TBI 6 10 3 15 10 5 4 11
Total 8 35 6 73 19 11 6 19
p < 0.01* p = 0.01 p = 0.00 p = 0.05 p < 0.00* p = 0.00* p = 0.01* p < 0.00

TBI, traumatic brain injury; FT/BC, basilar skull fractures; FT, craniofacial fractures; ECD, diffuse cerebral edema; HSG, subgaleal hematoma; HSA, subarachnoid hemorrhage;
ACSH, area of cerebral contusion with hemorrhagic suffusion; CSEP, extraparenchymal blood collection. * Fishers exact test; Chi-square test.

The male individuals predominance (80.4%)

Table 2 Statistical correlation between the different types of TBI and number of patients above 50
years of age who required orotracheal intubation. was compatible with the city of Sorocaba,
an urban area with about 700,000 inhabit-
Orotracheal intubation Age > 50 years
ants.
Mild TBI 2 2 Adolescents and young adults are the
Moderate TBI 1 1 majority of TBI patients, as described in
Severe TBI 15 15 previous studies(17-23). In the present study,
Total 18 18 79.4% (81/102) of the patients were younger
p < 0.0001* p < 0.0001 than 50 years of age. The decrease in the
TBI, traumatic brain injury. * Fishers exact test; Chi-square test. incidence of TBI in the age group > 50 years

Radiol Bras. 2011 Jan/Fev;44(1):3541 39

Morgado FL et al. Correlation between GCS and CT findings in traumatic brain injury
is due to the lesser exposure to external
factors, such as violence and traffic acci-
dents(1719,24). In the present study, the in-
cidence of automobile accidents (52.9%)
was in agreement with data reported by
other authors(25). In second place, fall from
height was the cause in 20.6% of cases.
Such data vary with the studied population:
the incidence of automobile accidents is
highest in dense urban areas, and violence
may be the first cause in economically un-
derdeveloped areas(13). Falls from height
are more prevalent in the elderly population
or in location with longer life expectancy(26).
In the sample of the present study,
86.3% (88/102) of the patients presented
one or more risk factors related to the
trauma (headache, vomiting, convulsion,
amnesia and/or syncope), and only 24.5%
(25/102) presented one or more of the un-
related risk factors (coagulopathy, use of
alcohol or drugs, previous neurological
surgery, epilepsy, age > 50 years and smok-
ing). Such data did not present any statis-
tical significance as compared with the dif-
ferent types of TBI (p > 0.136). Even
though whites were predominant in the
studied population, 79.4% (81/102), no
statistical significance was observed in the
correlation between race and types of TBI
(p > 1.0).
Differences in CT findings in cases of
TBI vary according to the trauma severity,
i.e., in accordance with the GCS scores.
The difficulty in comparing the tomo-
graphic findings is attributable to the scar-
city of scientific studies describing the to-
mographic findings after TBI in the litera-
ture.
The incidence of mild TBI was 82.4%
(84/102), while moderate TBI was ob-
served in 2.0% (2/102), and severe TCI in
15.6% of the patients (16/102), in agree-
ment with the study developed by Bruns &
Hauser(24), where mild TBI incidence rep-
resented 80% of all their cases, while mod-
erate and severe TBI represented 10% each.
Lower mild TBI incidences were reported
by other authors(2729); however in such
studies, extracranial alterations were ex-
cluded.
In the present study, among alterations
associated with mild TBI, subgaleal he-
matomas were present in 66.6% (56/84) of
the cases and craniofacial fractures in
40
28.5% (24/84). Some authors have reported
that the most frequent lesions in mild TBI
were subgaleal and palpebral hematomas,
fractures and cerebral contusions(30), others
described craniofacial fractures as the most
frequent lesions(28), and one study demon-
strated the prevalence of cerebral contu-
sions (26.8%), extradural hematomas
(6.8%), subarachnoid hemorrhage (5.7%)
and subdural hematomas (4.4%) in patients
with mild TBI(29).
In moderate TBI, the most common
finding was also subgaleal hematoma
(100%). Bone fractures, subarachnoid
hemorrhage, area of cerebral contusion
with hemorrhagic suffusion and diffuse
cerebral edema presented approximately
the same incidence (50%). Several studies
report that, in moderate TBI, the main to-
mographic findings were external hemato-
mas, fractures and contusions; in the
present study, however, higher incidence
rates were observed in all findings, such as
the case of subarachnoid hemorrhage.
In severe TBI there was a significant in-
crease in the incidence of all CT findings,
with a rate of 100% of abnormalities, the
most common ones corresponding to: sub-
arachnoid hemorrhage in 62.5% (10/16),
craniofacial fractures in 62.5% (10/16),
basilar skull fractures in 37.5% (6/16) and
association of three or more findings in
68.7% (11/16). One half of the patients
with diffuse cerebral edema presented se-
vere TBI. Such data demonstrate that the
CT findings with worst prognosis present
a higher incidence in cases of severe
TBI(31,32).
Advanced age has been described as in-
dependent variable associated with worst
prognosis. In the present study, 100% of the
patients above 50 years of age required
orotracheal intubation at the moment of the
first aid and had greater chances of present-
ing severe TBI, corroborating the findings
reported in other studies(33,34).
In the present study, low GCS scores
were considered as a severity risk factor in
association with a greater number of tomo-
graphic findings. Patients with TBI and low
GCS scores are affected by cerebral inju-
ries with more devastating effects and
present with a tendency for hemodynamic
instability as observed in other stud-
ies(12,33,3537).
CONCLUSIONS
In the present study, statistical signifi-
cance was observed between GCS and the
following variables: CT findings, need for
orotracheal intubation and coded age. The
lower the GCS score, the more severe were
the TBI and CT findings, with the predomi-
nance of diffuse cerebral edema, basilar
skull fracture and subarachnoid hemor-
rhage. Need for orotracheal intubation was
observed in 18 patients (17.6%), and was
found in all the patients with severe TBI
(83%), contributing as an ancillary negative
prognostic factor in the management of pa-
tients with polytrauma. Age above 50 years
was another factor of worst prognosis, with
100% chance of need for orotracheal intu-
bation at the moment of the first aid; and
the greater incidence of severe TBI with
significant CT findings. Thus, it is con-
cluded that the use of CT is critical in the
initial evaluation and prognosis of patients
with TBI.
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